PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: July 17, 2000.
Purpose: To update and rewrite regulations for people who provide services and/or equipment to medical assistance clients and repeal duplicative and/or unnecessary sections in chapter 388-87 WAC. One portion of WAC 388-502-0205 (which is being repealed) is incorporated in WAC 388-502-0020, and the remainder is covered in federal antidiscrimination rules.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-87-005, 388-87-007, 388-87-008, 388-87-010, 388-87-011, 388-87-012, 388-87-200, and 388-502-0205.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.530.
Adopted under notice filed as WSR 00-09-043 on April 14, 2000.
Changes Other than Editing from Proposed to Adopted Version: References to Medical Assistance Administration were changed to "the department" where appropriate.
In WAC 388-502-0010:
• Changed "podiatrists" to "podiatric physicians."
• Added ambulance services (ground and air), neurodevelopmental centers, and nondurable medical equipment and supplies.
• Clarified that DSHS enters into other contracts when necessary to provide other services (currently in WAC 388-87-007).
• Added social workers to the list of providers that MAA does not enroll (they are paid through other enrolled providers).
In WAC 388-502-0020:
• Added that providers need to keep dental photographs and teeth models in the client's records.
• Clarified that providers need to keep their records longer than 6 years if required to do so by other laws or regulations.
• Added that providers need to include a written statement when billing the department (currently in WAC 388-87-007, which is being repealed).
In WAC 388-502-0030:
• Clarifies when the department terminates enrollment (as well as suspends or denies enrollment).
• Clarified that the department terminates or suspends enrollment when the provider's certification, accreditation, or registration is suspended or revoked.
• Added that the department may terminate if the provider does not disclose ownership or control information (currently in WAC 388-87-008, which is being repealed).
• Added that the department is not obligated to enroll all eligible providers who request enrollment (currently in WAC 388-87-005, which is being repealed).
In WAC 388-502-0100:
• Included conditions under which MAA would pay for services for a client who was later found to have been ineligible on the date of service (currently in WAC 388-87-010).
• Clarified how the department pays when Medicare and Medicaid both cover a service, and when only Medicare covers a service.
These changes were made in response to public comments and/or to include provisions that are in current rules (being repealed) and inadvertently omitted in these rules.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 5, Amended 0, Repealed 8.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 5, Amended 0, Repealed 8.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 5, Amended 0, Repealed 8. Effective Date of Rule: Thirty-one days after filing.
July 17, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2704.9The department reimburses enrolled providers for covered medical services, equipment and supplies they provide to eligible clients.
(1) To be eligible for enrollment, a provider must:
(a) Be licensed, certified, accredited, or registered according to Washington state laws and rules; and
(b) Meet the conditions in this chapter and chapters regulating the specific type of provider, program, and/or service.
(2) To enroll, an eligible provider must sign a core provider agreement or a contract with the department and receive a unique provider number.
(3) Eligible providers listed in this subsection may request enrollment. Out-of-state providers listed in this subsection are subject to conditions in WAC 388-502-0120.
(a) Professionals:
(i) Advanced registered nurse practitioners;
(ii) Anesthesiologists;
(iii) Audiologists;
(iv) Chiropractors;
(v) Dentists;
(vi) Dental hygienists;
(vii) Denturists;
(viii) Dietitians or nutritionists;
(xiv) Maternity case managers;
(x) Midwives;
(xi) Occupational therapists;
(xii) Ophthalmologists;
(xiii) Opticians;
(xiv) Optometrists;
(xv) Orthodontists;
(xvi) Osteopaths;
(xvii) Podiatric physicians;
(xviii) Physicians;
(xix) Physical therapists;
(xx) Psychiatrists;
(xxi) Psychologists;
(xxii) Registered nurse delegators;
(xxiii) Registered nurse first assistants;
(xxiv)Respiratory therapists;
(xxv) Speech/language pathologists;
(xxvi) Radiologists; and
(xvii) Radiology technicians (technical only);
(b) Agencies, centers and facilities:
(i) Adult day health centers;
(ii) Ambulatory services (ground and air);
(iii) Ambulatory surgery centers (Medicare-certified);
(iv) Birthing centers (licensed by the department of health);
(v) Blood banks;
(vi) Chemical dependency treatment facilities certified by the department of social and health services (DSHS) division of alcohol and substance abuse (DASA), and contracted through either:
(A) A county under chapter 388-810 WAC; or
(B) DASA to provide chemical dependency treatment services;
(vii) Centers for the detoxification of acute alcohol or other drug intoxication conditions (certified by DASA);
(viii) Community AIDS services alternative agencies;
(ix) Community mental health centers;
(x) Early and periodic screening, diagnosis, and treatment (EPSDT) clinics;
(xi) Family planning clinics;
(xii) Federally qualified health care centers (designated by the Federal Health Care Financing Administration);
(xiii) Genetic counseling agencies;
(xiv) Health departments;
(xv) HIV/AIDS case management;
(xvi) Home health agencies;
(xvii) Hospice agencies;
(xviii) Hospitals;
(xix) Indian Health Service;
(xx) Tribal or urban Indian clinics;
(xxi) Inpatient psychiatric facilities;
(xxii) Intermediate care facilities for the mentally retarded (ICF-MR);
(xxiii) Kidney centers;
(xxiv) Laboratories (CLIA certified);
(xxv) Maternity support services agencies;
(xxvi) Neuromuscular and neurodevelopmental centers;
(xxvii) Nursing facilities (approved by DSHS Aging and Adult Services);
(xxviii) Pharmacies;
(xxix) Private duty nursing agencies;
(xxx) Rural health clinics (Medicare-certified);
(xxxi) Tribal mental health services (contracted through the DSHS mental health division); and
(xxxii) Washington state school districts and educational service districts.
(c) Suppliers of:
(i) Durable and nondurable medical equipment and supplies;
(ii) Infusion therapy equipment and supplies;
(iii) Prosthetics/orthotics;
(iv) Hearing aids; and
(v) Oxygen equipment and supplies;
(d) Contractors of:
(i) Transportation brokers;
(ii) Interpreter services agencies; and
(iii) Eyeglass and contact lens providers.
(4) Nothing in this chapter precludes the department from entering into other forms of written agreements to provide services to eligible clients.
(5) The department does not enroll licensed or unlicensed practitioners who are not specifically addressed in subsection (3) of this section, including, but not limited to:
(a) Acupuncturists;
(b) Counselors;
(c) Sanipractors;
(d) Naturopaths;
(e) Homeopaths;
(f) Herbalists;
(g) Massage therapists;
(h) Social workers; or
(i) Christian Science practitioners or theological healers.
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(1) Enrolled providers must:
(a) Keep legible, accurate, and complete charts and records to justify the services provided to each client, including, but not limited to:
(i) Patient's name and date of birth;
(ii) Dates of services;
(iii) Name and title of person performing the service, if other than the billing practitioner;
(iv) Chief complaint or reason for each visit;
(v) Pertinent medical history;
(vi) Pertinent findings on examination;
(vii) Medications, equipment, and/or supplies prescribed or provided;
(viii) Description of treatment (when applicable);
(ix) Recommendations for additional treatments, procedures, or consultations;
(x) X-rays, tests, and results;
(xi) Dental photographs and teeth models;
(xii) Plan of treatment and/or care, and outcome; and
(xiii) Specific claims and payments received for services.
(b) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains;
(c) Make charts and records available to DSHS, its contractors, and the US Department of Health and Human Services upon request, for six years from the date of service or longer if required specifically by federal or state law or regulation;
(d) Bill the department according to department rules and billing instructions;
(e) Include and sign the following statement with each bill submitted to the department for reimbursement: "I hereby certify under penalty of perjury, that the material furnished and service rendered is a correct charge against the state of Washington; the claim is just and due; that no part of the same has been paid and I am authorized to sign for the payee; and that all goods furnished and/or services rendered have been provided without discrimination on the grounds of race, creed, color, sex, religion, national origin, marital status, or the presence of any sensory, mental or physical handicap."
(f) Accept the payment from the department as payment in full;
(g) Follow the requirements in WAC 388-502-0160 and 388-538-095 about billing clients;
(h) Fully disclose ownership and control information requested by the department;
(i) Not pay a third party biller a percentage of amounts collected, or discount client accounts to a third party biller;
(j) Provide all services without discriminating on the grounds of race, creed, color, age, sex, religion, national origin, marital status, or the presence of any sensory, mental or physical handicap; and
(k) Provide all services according to federal and state laws and rules, and billing instructions issued by the department.
(2) A provider may contact MAA with questions regarding its programs. However, MAA's response is based solely on the information provided to MAA's representative at the time of inquiry, and in no way exempts a provider from following the laws and rules that govern the department's programs.
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(1) The department terminates enrollment or does not enroll or re-enroll a provider if, in the department's judgement, it may be a danger to the health or safety of clients.
(2) Except as noted in subsection (3) of this section, the department does not enroll or re-enroll a provider to whom any of the following apply:
(a) Has a restricted professional license;
(b) Has been terminated, excluded, or suspended from Medicare/Medicaid; or
(c) Has been terminated by the department for quality of care issues or inappropriate billing practices.
(3) The department may choose to enroll or re-enroll a provider who meets the conditions in subsection (2) of this section if all of the following apply:
(a) The department determines the provider is not likely to repeat the violation that led to the restriction or sanction;
(b) The provider has not been convicted of other offenses related to the delivery of professional or other medical services in addition to those considered in the previous sanction; and
(c) If the United States Department of Health and Human Services (DHHS) or Medicare suspended the provider from Medicare, DHHS or Medicare notifies the department that the provider may be reinstated.
(4) The department gives thirty days written notice before suspending or terminating a provider's enrollment. However, the department suspends or terminates enrollment immediately if any one of the following situations apply:
(a) The provider is convicted of a criminal offense related to participation in the Medicare/Medicaid program;
(b) The provider's license, certification, accreditation, or registration is suspended or revoked;
(c) Federal funding is revoked;
(d) By investigation, the department documents a violation of law or contract;
(e) The MAA medical director or designee determines the quality of care provided endangers the health and safety of one or more clients; or
(f) The department determines the provider has intentionally used inappropriate billing practices.
(5) The department may terminate a provider's number if:
(a) The provider does not disclose ownership or control information;
(b) The provider does not submit a claim to the department for twenty-four consecutive months;
(c) The provider's address on file with the department is incorrect;
(d) The provider requests a new provider number (e.g., change in tax identification number or ownership); or
(e) The provider voluntarily withdraws from participation in the medical assistance program.
(6) Nothing in this chapter obligates the department to enroll all eligible providers who request enrollment.
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(1) The department reimburses for medical services furnished to an eligible client when all of the following apply:
(a) The service is within the scope of care of the client's medical assistance program;
(b) The service is medically or dentally necessary;
(c) The service is properly authorized;
(d) The provider bills within the timeframe set in WAC 388-502-0150;
(e) The provider bills according to department rules and billing instructions; and
(f) The provider follows third-party payment procedures.
(2) The department is the payer of last resort, unless the other payer is:
(a) An Indian health service;
(b) A crime victims program through the department of labor and industries; or
(c) A school district for health services provided under the Individuals with Disabilities Education Act.
(3) The provider must accept Medicare assignment for claims involving clients eligible for both Medicare and medical assistance before MAA makes any payment.
(4) The provider is responsible for verifying whether a client has medical assistance coverage for the dates of service.
(5) The department may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service at the time it was provided if:
(a) The department considered the person eligible at the time of service;
(b) The service was not otherwise paid for; and
(c) The provider submits a request for payment to the department.
(6) The department does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the department.
(7) Information about medical care for jail inmates is found in RCW 70.48.130.
(8) The department pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the department, whichever is lower.
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(1) The department pays the deductible and coinsurance amounts for a client participating in Parts A and/or B of Medicare (Title XVIII of the Social Security Act) when the:
(a) Total reimbursement to the provider from Medicare and the department does not exceed the rate in the department's fee schedule; and
(b) Provider accepts assignment for Medicare payment.
(2) The department pays the deductible and coinsurance amounts for a client who has Part A of Medicare. If the client:
(a) Has not exhausted lifetime reserve days, the department considers the Medicare diagnostic related group (DRG) as payment in full; or
(b) Has exhausted lifetime reserve days during an inpatient hospital stay, the department considers the Medicare DRG as payment in full until the Medicaid outlier threshold is reached. After the Medicaid outlier threshold is reached, the department pays an amount based on the policy described in the Title XIX state plan.
(3) If Medicare and Medicaid cover the service, the department pays only the deductible and/or coinsurance up to Medicare or Medicaid's allowed amount, whichever is less. If only Medicare and not Medicaid covers the service, the department pays only the deductible and/or coinsurance up to Medicare's allowed amount.
(4) The department bases its outlier policy on the methodology described in the department's Title XIX state plan, methods, and standards used for establishing payment rates for hospital inpatient services.
(5) The department pays, according to department rules and billing instructions, for Medicaid covered services when the client exhausts Medicare benefits.
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The following sections of the Washington Administrative Code are repealed:
| WAC 388-87-005 | Payment -- Eligible providers defined. |
| WAC 388-87-007 | Medical provider agreement. |
| WAC 388-87-008 | Disclosure by providers -- Information on ownership and control. |
| WAC 388-87-010 | Conditions of payment -- General. |
| WAC 388-87-011 | Conditions of payment -- Medicare deductible and coinsurance -- When paid by department. |
| WAC 388-87-012 | Conditions of payment -- Consultant's and specialist's services and fees. |
| WAC 388-87-200 | Payment for jail inmates medical care. |
The following section of the Washington Administrative Code is repealed:
| WAC 388-502-0205 | Civil rights. |